9/14/2015

InstituteforHealthcareImprovement:FailureModesandEffectsAnalysisToolProcessDataReport

FailureModesandEffectsAnalysis(FMEA)Tool

RecognitionandReductionofDeliriumintheICU
UnitedStates
HospitalCommunity

Aim:Decreaseincidenceand/orseverityofdeliriumintheICU
ProcessData
Date:04/18/2015
Step

Description

DeliriumScreeningIncorrectlyUsed

FailureMode

Causes

Effects

CAMandRAAStoolused
interchangeablywithnoclear
guidelinesonwhentocontact
provider,scalesusedon
patientswithdementia
insteadofdelirium

Notenougheducationon
differencebetweenCAMand
RAAS,perreportonething
doneandnursefollowing
continuestodothesame
thing!

Incorrectresults,fluctuation
commonlyseenasnormal,
uncertaintyinhowmuch
sedationtouse

Step

Description

SedationVacationInconsistent

FailureMode

Causes

Effects

Nurseshavenostandardto
weandownfor"sedation
vacation",e.g..noset
amounttoturndown,noset
amountoftimeortimeof
day

Pharmokineticsarehighly
variableandnursesdon't
wanttocausepainorstress
fortheirpatientsbyturning
downsedationtoofar

Highlyvariabletestingwith
differentresultsdepending
onthenurse

Step

Description

NoBaselineCAMScore

FailureMode

Causes

NobaselineCAMorRAASfor Unabletoobtainbaseline,
comparison
baselinenotdocumented,
smallchangesnot
documented

Effects
Smallchangesmaycontinue
tobuildandgoundetectedor
"fallthroughthecracks"

Occ Det Sev RPN Actions

6

144 Moreeducationonuseof
deliriumscreeningtooland
medicationsusedtosedate

Occ Det Sev RPN Actions

10

640 Developaguidelineforhow
muchsedationtostart
weaning,howlongtowait
beforetryingtoweanmore

Occ Det Sev RPN Actions

4

108 Standardizelocationof
wherebaselineis
documentedandmore
thoroughdocumentation

CalculatedTotals
TotalRiskPriorityNumberfortheprocess

892

Occ: LikelihoodofOccurrence(110)
Det: LikelihoodofDetection(110)
NOTE: 1=VerylikelyitWILLbedetected

10=VerylikelyitWILLNOTbedetected

Sev: Severity(110)
RPN:RiskPriorityNumber(OccDetSev)

Annotation
None

http://app.ihi.org/Workspace/tools/fmea/ProcessDetailDataReport.aspx?ToolId=19663&ScenarioId=21602&Type=1

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